Can Research Make Health Systems Strengthening Sexier?

Today, researchers, donors, policymakers, and advocates from around the world met in Montreux, Switzerland for the first ever Global Symposium for Health Systems Research.  The objectives of the conference, laid out in an interesting Debategraph , are to collectively establish a science-based approach to accelerate universal health coverage.  The topic of health systems failure sounds positively humdrum to many  of us who have worked in global health. Resources for building, monitoring and evaluating health systems have been woefully inadequate for decades, so, why the interest in health systems now?Quick Response:In the last decade, a critical health threat—AIDS—emerged in low income and middle income countries, especially in sub-Saharan Africa. The unprecedented global response and funding that poured into disease-burdened countries brought health systems failure into high relief, catalyzing interest from donors, country governments, implementers, and researchers to make health systems work for a broad range of health priorities.Longer Version:The AIDS pandemic and global response exposed health system failure as a complex problem, requiring more than financial resourcesWhen funding for AIDS grew to unprecedented levels in the last decade (in 2009, estimated to be $15.9 billion dollars from all sources), global health became a key development issue, highlighting several challenges that aren’t easily solved by money alone—including functional and comprehensive health systems. In 2008, my colleagues and I published a report (see here) from CGD’s HIV/AIDS Monitor to describe the ways in which big AIDS donors (such as for PEPFAR and the Global Fund for Aids, TB and Malaria) were either interacting with or avoiding failing health systems in three African countries to achieve ambitious AIDS program goals. The report found that even with the new global health resources available, three key components of the health system: health information systems; supply chains; and the health work force, remained weak beyond AIDS-specific programs.  Our recommendations urged donors and countries to seize the opportunity to fix health systems to respond to a broad range of health priorities, learning from some of the best practices that AIDS programs had put into place. Others began to comment on and examine the impact of AIDS funding on health systems in developing countries (see here, here and here), but found it difficult to define a health system, let alone measure how it has been strengthened or weakened by surges in AIDS funding.New Resources, new policies, and now new research are making health systems sexy!In 2009, President Obama announced the Global Health Initiative (GHI), one of the three key development initiatives of this administration’s new development policy.  With a price tag of $63 billion dollars over 6 years (FY 2009-14), the GHI focuses on 9 target areas including: HIV/AIDS, Malaria, Tuberculosis, Maternal & Child Health, Nutrition, Family Planning & Reproductive Health, Neglected Tropical Diseases,  AND (drumroll) health systems strengthening!!  In September of this year at a public event in Washington, D.C., Raj Shah, Administrator, USAID said, “I, in particular, think a good health system can be quite sexy!” The U.S. government’s effort and other efforts to tackle weak health systems as a key development objective is creating the space to address a long standing and not-so-sexy global development challenge.  But a serious impediment to progress on this front is the lack of a solid evidence base that can support the theory and practice of strengthening health systems.  For example, researchers and policymakers have been struggling with developing a set of indicators that can measure the performance of health systems, so that we can measure the effects/impact of health system strengthening interventions. The meeting of global health minds in Montreux to establish and develop a science based approach to strengthening health systems is long overdue.The Challenges Ahead:Relating health systems performance to health outcomesThe research agenda that colleagues establish in Montreux should include research that is operational and important for monitoring the status and performance of a health system, but I’m looking forward to learning more about how experts will propose research to study the links of a strong health system to better health outcomes for all.  After all, we are strengthening health systems as a means to an end, and not an end in and of itself.  See David Bishai’s excellent post cautioning us “that our discourse on health systems should not forget that health systems are not the foremost determinants of the health of nations. We would have to open the concept of health systems to include sanitation, water, housing, roads, schools, jobs, and political systems to make health systems truly include the determinants of health.” Time is of essence Sound scientific research is very welcome but it is going to take some time for evidence to emerge. I’m worried that the U.S. and other donors have made big promises to their partner countries about strengthening their health systems, but are struggling to describe what a successful effort will look like on an annual basis, and at the end of their programs.  This is critical, not just politically for President Obama and his administration, but for continued investments in global health. I’m hoping that the time lag between research results and useful policy/program applications will not take as long as the establishment of a science-based approach to strengthening and measuring health systems.